Carius said he's seeing more patients end up back in the ER because they were unable to get an appointment with their doctors.

The culprit, he said, is a physician shortage that has put a major strain on doctors. Over-scheduled doctors still practicing are reluctant to take on new patients and have a difficult time scheduling appointments for existing patients.

"Often, the schedule for a primary care doctor is so full, there's no room to squeeze in a patient the next day for emergency follow-up," Carius said. Thus, he said, the patients often return to their local emergency department, and they're not any better. Or they're worse.

"We're really stuck between a rock and a hard place where we have a greater need to refer patients, but less physicians to meet that need," he said.

Experts said the gap between the number of physicians and the number of patients is increasing.

There are many reasons for the shortage, including the advent of health care reform and the fact that many doctors are approaching retirement age. Whatever the cause, the shortage has become a hardship for doctors and patients.

Too few serving too many

In 2010, there was a shortage of 13,700 physicians nationwide, according to the Association of American Medical Colleges, a nonprofit representing faculty members, medical students, and resident physicians at medical schools, teaching hospitals and other institutions.

The gap between doctors and patients is expected to get even wider in 2014, when the biggest piece of the health care reform package passed in 2010 goes into effect, giving 32 million more Americans access to health insurance. The Association of American Medical Colleges's Center for Workforce Studies predicts that the shortage will grow to 62,900 doctors by 2015 and to 91,500 by 2020.

The U.S. Department of Health and Human Services, however, contests that number. It says the shortfall created by the Affordable Care Act will be much lower. HHS predicts that the expansion of coverage will increase the number of primary care visits in 2019 by between 15 and 24 million and will require between 4,300 to 6,900 additional primary care physicians.

Though this is much lower than what AAMC is predicting, both AAMC and the government predict some sort of shortfall.

Effects of the shortage are evidenced in patient responses about the care they receive. In 2008, the Connecticut State Medical Society surveyed about 500 of its members on a range of issues, including patient access to care. The survey found that on average a new patient would have to wait 18 days for a routine office visit and that existing patients would also have a long wait -- 16 days to see a pediatrician, 15 days for an internist and seven days for a family physician.

The survey also found that 28 percent of internists and 26 percent of family physicians weren't accepting new patients. About half of those surveyed said that they had difficulty in obtaining referrals to doctors. Health plan restrictions were cited as one of the major reasons, followed by the supply of physicians in specialty areas. Though the data is a few years old, the same problems exist today, said Matthew Katz, executive vice president and chief executive officer of the Connecticut State Medical Society.

Faye Benedetti of Milford agreed. Benedetti was at the office of general practitioner Dr. Steven Saunders in Milford on Thursday waiting for her husband, Dan, who is a patient there. Both the Benedettis said it's fairly easy for Dan to get an appointment with Saunders, who generally does a good job of being accessible to patients. But Faye Benedetti said she's had less pleasant experiences trying to get in a doctor's office, particularly with the physician she used to see. "It would take me an hour to get through (on the phone)," she said.

But, as an administrator at an internal medicine practice in Westport, Benedetti said she's seen the effects of the shortage from both sides. Though the physicians at her office try to get in all their patients in a timely fashion, Benedetti said she knows they are under a lot of strain. "I think this is just tough in general on doctors and patients," she said

Though his waiting room seemed relatively quiet the day the Benedettis were there, Saunders said he knows that many of his colleagues are under pressure -- particularly his fellow primary care physicians. Though all areas of the medical profession are facing shortages, the field of primary care is the hardest hit, with a shortage of 9,000 doctors in 2010 and predicted shortage of about 45,000 by 2020.

"My profession is dying on the vine," said Saunders, also president of the medical staff at Milford Hospital.

increasing pressures

Along with health care reform and the millions of new patients it will create, experts said several factors are contributing to the physician shortage. One cause mentioned by several doctors and experts is the ongoing debate about Medicare reimbursements. The payments doctors receive from caring for Medicare patients are constantly in danger of being cut. Last week, federal lawmakers prevented a 27.4 percent cut in Medicare physician payment rates planned for March 1 and froze current payment rates through the end of this year.

Still, concerns about reimbursement have led many doctors to stop taking Medicare patients. Another CSMS survey, the results of which were released in January, showed that, of the 354 doctors polled, 19 percent were limiting appointments for patients covered by Medicare or TRICARE, which covers those in the military, or not accepting new patients enrolled in these programs. Saunders, for instance, said he stopped taking new Medicare patients a few years ago. The impact was even greater among doctors in the state's rural counties -- Windham, Tolland and Litchfield -- 44 percent of whom said they had reduced the number of patients they see who were enrolled in these programs.

Another factor in the doctor shortage is the aging of the physician population -- and the dearth of new doctors waiting in the wings to replace them. The AAMC predicts that nearly one third of the nation's physicians will retire within the next ten years and there are concerns that there won't be enough new doctors coming in to replace the retirees. Though the AAMC reports that the number of medical schools is increasing -- and that there will be an additional 7,000 graduates every year over the next decade -- AAMC director of federal affair Christiane Mitchell said there is a shortage of medical residency programs. Also, the government froze Medicare support for physician training in 1997 and hasn't lifted it.

Other obstacles to new doctors joining the workforce include the high cost of medical education. Last week, the U.S. Department of Health and Human reported that the government was giving $9.1 million in funding to medical students in 30 states -- including Connecticut -- who will serve as primary care doctors in underserved areas.

However, Mitchell said it's not enough. "In the context of such need, this is really a drop in the bucket," she said.

Locally, Saunders and other doctors worried about the lack of medical students choosing primary care as their field of specialty. Saunders, also a clinical professor of medicine for the Yale University School of Medicine, said he's seen interest in primary care dip considerably in recent years among the students he works with. "Very few, if any, end up going into primary care," he said. "It's probably one of the most difficult and challenging specialties in medicine."

It's also among the lowest paid, according to the American Medical Group Association, which represents a variety of medical groups, including medical practices, independent practice associations and integrated health care delivery systems. In its 2011 Medical Group Compensation and Financial Survey, the AMGA found that doctors in family medicine, a form of primary care received an average of $208,658 a year in compensation. Compare that to cardiologists, who garner $422,921 a year or those in general surgery, who make about $367,315 a year.

Saunders said lower compensation, along with longer hours, are big reason why quality medical students stay away from primary care. "It used to be that the best and brightest went into (primary care) because it was the most challenging and rewarding," he said.

Though he still considers it a terrific field to be in, Saunders understands why primary care has curb appeal -- not just to aspiring doctors, but to existing ones. "A lot of doctors my age are leaving and finding other careers," he said.

Like the other experts interviewed, Saunders said something has to change. Otherwise, he said, the shortage will continue to escalate and more patients will be unable to access the care they need. "It's just getting harder and harder for patients to find a general practitioner," he said.